Systems and methods for performing minimally invasive surgery

ABSTRACT

Minimally invasive surgical techniques are used to obtain access to vertebrae while protecting soft tissues in the surrounding area. The dilators may be used to provide a working channel through which the operation is performed. Standard dilators may be used with a robotic surgical system to provide precise guidance of surgical tools. A dilator may be held by the robot and automatically repositioned when the surgeon adjusts a trajectory for performing the surgery. The dilator itself may be used as a surgical instrument guide along with dilator adaptors that adjust the diameter of a portion of the dilator to allow for different sized tools to be guided by the dilator. Alternatively, surgical instrument guides may also be held by the robotic arm such that tools are guided by a surgical instrument guide through the dilator to perform a medical procedure.

CROSS-REFERENCE TO RELATED APPLICATIONS

This Patent Application is a continuation application of U.S. patentapplication Ser. No. 14/744,624, filed on Jun. 19, 2015 (published asU.S. Pat. Pub. No. 2015-0366624), which is a non-provisional patentapplication claiming priority to U.S. Provisional Patent Application No.62/014,531, filed Jun. 19, 2014 (expired), the entire contents of all ofwhich are hereby incorporated by reference in their entireties for allpurposes.

BACKGROUND OF THE INVENTION

Robotic-assisted surgical systems have been developed to improvesurgical precision and enable the implementation of new surgicalprocedures. For example, robotic systems have been developed to sense asurgeon's hand movements and translate them to scaled-downmicro-movements and filter out unintentional tremors for precisemicrosurgical techniques in organ transplants, reconstructions, andminimally invasive surgeries. Other robotic systems are directed totelemanipulation of surgical tools such that the surgeon does not haveto be present in the operating room, thereby facilitating remotesurgery. Feedback-controlled robotic systems have also been developed toprovide smoother manipulation of a surgical tool during a procedure thancould be achieved by an unaided surgeon.

However, widespread acceptance of robotic systems by surgeons andhospitals is limited for a variety of reasons. Current systems areexpensive to own and maintain. They often require extensive preoperativesurgical planning prior to use, and they extend the required preparationtime in the operating room. They are physically intrusive, possiblyobscuring portions of a surgeon's field of view and blocking certainareas around the operating table, such that a surgeon and/or surgicalassistants are relegated to one side of the operating table. Currentsystems may also be non-intuitive or otherwise cumbersome to use,particularly for surgeons who have developed a special skill or “feel”for performing certain maneuvers during surgery and who find that suchskill cannot be implemented using the robotic system. Finally, roboticsurgical systems may be vulnerable to malfunction or operator error,despite safety interlocks and power backups.

Spinal surgeries often require precision drilling and placement ofscrews or other implements in relation to the spine, and there may beconstrained access to the vertebrae during surgery that makes suchmaneuvers difficult. Catastrophic damage or death may result fromimproper drilling or maneuvering of the body during spinal surgery, dueto the proximity of the spinal cord and arteries. Common spinal surgicalprocedures include a discectomy for removal of all or part of a disk, aforaminotomy for widening of the opening where nerve roots leave thespinal column, a laminectomy for removal of the lamina or bone spurs inthe back, and spinal fusion for fusing of two vertebrae or vertebralsegments together to eliminate pain caused by movement of the vertebrae.

Spinal surgeries that involve screw placement require preparation ofholes in bone (e.g., vertebral segments) prior to placement of thescrews. Where such procedures are performed manually, in someimplementations, a surgeon judges a drill trajectory for subsequentscrew placement on the basis of pre-operative CT scans. Other manualmethods which do not involve usage of the pre-operative CT scans, suchas fluoroscopy, 3D fluoroscopy or natural landmark-based, may be used todetermine the trajectory for preparing holes in bone prior to placementof the screws. In some implementations, the surgeon holds the drill inhis hand while drilling, and fluoroscopic images are obtained to verifyif the trajectory is correct. Some surgical techniques involve usage ofdifferent tools, such as a pedicle finder or K-wires. Such proceduresrely strongly on the expertise of the surgeon, and there is significantvariation in success rate among different surgeons. Screw misplacementis a common problem in such surgical procedures.

Image-guided spinal surgeries involve optical tracking to aid in screwplacement. However, such procedures are currently performed manually,and surgical tools can be inaccurately positioned despite virtualtracking. A surgeon is required to coordinate his real-world, manualmanipulation of surgical tools using images displayed on a twodimensional screen. Such procedures can be non-intuitive and requiretraining, since the surgeon's eye must constantly scan both the surgicalsite and the screen to confirm alignment. Furthermore, procedural errorcan result in registration inaccuracy of the image-guiding system,rendering it useless, or even misleading.

Certain force feedback systems are used by surgeons in certainprocedures; however such systems have a large footprint and take upvaluable, limited space in the operating room. These systems alsorequire the use of surgical tools that are specially adapted for usewith the force feedback system, and the training required by surgeons tooperate such systems can be significant. Moreover, surgeons may not beable to use expertise they have developed in performing spinal surgerieswhen adapting to use of the current force feedback systems. Suchsystems, while precise, may require more surgical time and moreoperating room preparation time to ready placement of the equipment forsurgery. Thus, there is a need for systems, apparatus, and methods thatprovide enhanced precision in performing surgeries such as spinalsurgeries.

SUMMARY OF THE INVENTION

Described herein are systems, apparatus, and methods for preciseplacement and guidance of tools during surgery, particularly spinalsurgery, using minimally invasive surgical techniques. The systemfeatures a portable robot arm with end effector for precise positioningof a surgical tool. Minimally invasive surgical techniques are used toobtain access to vertebrae while protecting soft tissues in thesurrounding area. These techniques minimize blood loss, postoperativepain, and scaring while providing for faster recoveries. The disclosedtechnology utilizes robotic surgical systems with minimally invasivesurgical techniques and automated planning to enhance the precision inperforming surgeries, such as spinal surgeries.

During minimally invasive surgical procedures, dilators may be used tocreate a working channel through which an operation is performed. Thedilators may be a set of tubes with increasing diameters which areinserted into a small incision one at a time until the desired diameterof the working channel is achieved. The dilators may be used with arobotic surgical system (e.g., attached to the robotic arm) to perform aminimally invasive surgery. This allows the usage, in certainembodiments, of standard dilators and a robotic surgical system toprovide precise guidance of surgical tools through a dilator and greaterflexibility. The dilator may be held by the robot and automaticallyrepositioned when the surgeon adjusts the trajectory along which, forexample, a hole is prepared in a vertebra. Adjustment of the endeffector of the robotic surgical system automatically adjusts an angleand/or position of the dilator attached to the robot with respect to thevertebrae and aligns an axis defined by the dilator with a desiredtrajectory during a surgical procedure without removal of the dilatorfrom the patient tissue during the repositioning.

For example, first dilator may be used to access a vertebrae of apatient through the patient's muscles and skin, thereby defining aworking channel for accessing the vertebrae. One or more subsequentdilators may be slid over the first dilator. Each of the one or moresubsequent dilators are configured to be positioned over the precedingdilators and increase the size of the working channel. Each dilatorexcept the last added dilator is configured to be removed from thepatient thereby leaving the last added dilator. The last added dilatoris configured to be attached to an end effector of a robotic arm using adilator fixator. A manipulator is configured to allowrobotically-assisted or unassisted positioning and/or movement of thelast added dilator by a user with at least four degrees of freedom toalign an axis defined by the last added dilator with respect to thevertebrae. Adjustment of the manipulator automatically adjusts an angleand/or position of the attached dilator with respect to the vertebraeand aligns an axis defined by the attached dilator with a desiredtrajectory during a surgical procedure without removal of the attacheddilator from the patient tissue during the repositioning.

The system requires only minimal training by surgeons/operators, isintuitive to use, and has a small footprint with significantly reducedobstruction of the operating table. The system works with existing,standard surgical tools, does not require increased surgical time orpreparatory time, and safely provides the enhanced precision achievableby robotic-assisted systems. Moreover, the system allows for a desiredtrajectory (e.g., for a drill guide during spinal surgery) to be set ina variety of manners based on the circumstances of the surgery. Forexample, some surgical procedures are planned pre-operatively with thesurgeon defining the desired position of an implant using imagingtechnology, such as CT images (e.g., 3D CT images). The desired positionof the implant may also be determined and proposed by the system. In theoperating room the surgeon may be guided by the robotic system (e.g.,robotic guidance of the surgical tools) to accurately execute theplanning.

A mobile cart houses a robot arm with an end effector that holds variousstandard surgical tools/implants, such as a drill or screw. Positioningsuch surgical tools with precision is critical. The robot arm providesmore precise, stable placement of such tools than can be achievedmanually, where placement is guided, yet intuitive. The mobile cartpermits easy set-up and use of the system. Once stabilization isengaged, the mobile cart is secured in place on the operating room floorand cannot move. In certain embodiments, the robot cart houses therobot, robot controller, supervisor interlock system, power system,riding system, and interface to the navigation system.

In one aspect, the disclosed technology includes a method of performingminimally invasive spinal surgery with a robotic surgical system, themethod including: maneuvering a first dilator to access a vertebrae of apatient through the patient's muscles and skin, wherein the dilatordefines a working channel for accessing the vertebrae; increasing thesize of the working channel (e.g., using one or more dilators subsequentto the first dilator, whereby a subsequent dilator is temporarilysecured in the patient tissue); attaching the first dilator or thesubsequent dilator to the end effector of the robotic arm using adilator fixator; following attachment of the first or a subsequentdilator to the end effector, repositioning the end effector therebyautomatically adjusting an angle and/or position of the attached dilatorwith respect to the vertebrae and aligning an axis defined by theattached dilator with a desired trajectory during a surgical procedurewithout removal of the attached dilator from the patient tissue duringthe repositioning.

In certain embodiments, increasing the size of the working channelincludes: maneuvering a second dilator over the first dilator, whereinthe second dilator is sized and shaped to slide over the first dilatorand increase the size of the working channel; and after positioning thesecond dilator over the first dilator (and/or after positioning one ormore subsequent dilators over the preceding dilators), removing thefirst dilator (and/or other previous dilators except the final addeddilator) from the patient, thereby leaving the last added dilator,wherein the attached dilator is the last added dilator.

In certain embodiments, the attached dilator is the dilator with largestcircumference.

In certain embodiments, increasing the size of the working channelincludes: expanding the diameter of the first dilator thereby increasingthe diameter of the working channel, wherein the dilator attached to theend effector is the first dilator.

In certain embodiments, the method further includes placing a surgicalinstrument guide at least partially inside of, in front of, or adjacentto the attached dilator, wherein the surgical instrument guide is sizedand shaped to fit at least partially inside the attached dilator alongan axis defined by said dilator.

In certain embodiments, the end effector includes a surgical instrumentguide attached thereto, configured to hold and/or restrict movement of asurgical instrument therethrough.

In certain embodiments, the surgical instrument guide is at least one ofa drill bit guide, tap guide, screwdriver guide, screw guide, awl guide,and implant guide.

In certain embodiments, the surgical instrument is at least one of adrill bit, tap, screwdriver, screw, implant, and awl, wherein thesurgical instrument is configured to slide through the surgicalinstrument guide.

In certain embodiments, the attached dilator is configured to holdand/or restrict movement of a surgical instrument therethrough.

In certain embodiments, the method includes registering the patient,wherein registering the patient comprises identifying the transformationbetween the actual patient anatomy and one or more medical images;maneuvering the end effector towards the vertebrae on which the surgeonwill operate; determining, by a processor of a computing device, anideal implant trajectory; and providing, by the processor, for displayon a graphical user interface, the ideal implant trajectory for reviewby the surgeon, wherein (i) the surgeon may adapt the ideal implanttrajectory if needed using hands-on planning, and (ii) the surgeonacknowledges the ideal implant trajectory or the adapted trajectorythereby causing the acknowledged trajectory to be stored as the desiredtrajectory.

In certain embodiments, the method includes, prior to maneuvering theattached dilator: moving a mobile cart transporting a robotic surgicalsystem comprising a robotic arm in proximity to an operating table,wherein the robotic arm has an end effector; and stabilizing the mobilecart.

In another aspect, the disclosed technology includes a robotic surgicalsystem for performing minimally invasive surgery, the system including:a robotic arm with an end effector; a first dilator to access avertebrae of a patient through the patient's muscles and skin, whereinthe first dilator defines a working channel for accessing the vertebrae;one or more subsequent dilators sized and shaped to slide over the firstdilator and/or one or more of the one or more subsequent dilators,wherein: the one or more subsequent dilators comprise a last addeddilator, each of the one or more subsequent dilators are configured tobe positioned over the preceding dilators and increase the size of theworking channel, each dilator except the last added dilator isconfigured to be removed from the patient thereby leaving the last addeddilator, the last added dilator is configured to be attached to the endeffector of the robotic arm using a dilator fixator; and a manipulatorconfigured to allow robotically-assisted or unassisted positioningand/or movement of the end effector by a user with at least four degreesof freedom thereby automatically adjusting an angle and/or position ofthe last added dilator with respect to the vertebrae and aligning anaxis defined by the last added dilator with a desired trajectory duringa surgical procedure without removal of the last added dilator from thepatient tissue during the repositioning.

In certain embodiments, each one or more subsequent dilators have acircumference larger than the circumference of the first dilator, andthe one or more subsequent dilators increase the size of the workingchannel as each subsequent dilator is added.

In certain embodiments, the system includes a surgical instrument guideconfigured to be placed inside of the attached dilator, wherein thesurgical instrument guide is sized and shaped to fit at least partiallyinside the attached dilator along an axis defined by the dilator.

In certain embodiments, the end effector comprises the surgicalinstrument guide attached thereto, configured to hold and/or restrictmovement of a surgical instrument therethrough.

In certain embodiments, the surgical instrument guide is at least one ofa drill bit guide, tap guide, screwdriver guide, screw guide, awl guide,and implant guide.

In certain embodiments, the surgical instrument is at least one of adrill bit, tap, screwdriver, screw, implant, and awl, wherein thesurgical instrument is configured to slide through the surgicalinstrument guide.

In certain embodiments, the attached dilator is the dilator with largestcircumference.

In certain embodiments, the attached dilator is configured to holdand/or restrict movement of a surgical instrument therethrough.

In certain embodiments, the system includes a processor; and a memory,the memory storing instructions that, when executed by the processor,cause the processor to: store a transformation between the actualpatient anatomy and one or more medical images; determine an idealimplant trajectory; and provide, for display on a graphical userinterface, the ideal implant trajectory for review by the surgeon,wherein (i) the surgeon may adapt the ideal implant trajectory if neededusing hands-on planning, and (ii) the surgeon acknowledges the idealimplant trajectory or the adapted trajectory thereby causing theacknowledged trajectory to be stored as the desired trajectory.

In another aspect, the disclosed technology includes a robotic surgicalsystem for performing minimally invasive surgery, the system including:a robotic arm with an end effector; a dilator to access a vertebrae of apatient through the patient's muscles and skin, wherein: the dilatordefines a working channel for accessing the vertebrae; the dilator isconfigured to be expanded to increase the size of the working channel,the dilator is configured to be attached to an end effector of a roboticarm using a dilator fixator; and a manipulator configured to allowrobotically-assisted or unassisted positioning and/or movement of theend effector by a user with at least four degrees of freedom therebyautomatically adjusting an angle and/or position of the dilator withrespect to the vertebrae and aligning an axis defined by the dilatorwith a desired trajectory during a surgical procedure without removal ofthe dilator from the patient tissue during the repositioning.

In certain embodiments, the system includes a surgical instrument guideconfigured to be placed inside of the dilator, wherein the surgicalinstrument guide is sized and shaped to fit at least partially insidethe dilator along an axis defined by the dilator.

In certain embodiments, the end effector includes the surgicalinstrument guide attached thereto, configured to hold and/or restrictmovement of a surgical instrument therethrough.

In certain embodiments, the surgical instrument guide is at least one ofa drill bit guide, tap guide, screwdriver guide, screw guide, awl guide,and implant guide.

In certain embodiments, the surgical instrument is at least one of adrill bit, tap, screwdriver, screw, implant, and awl, wherein thesurgical instrument is configured to slide through the surgicalinstrument guide.

In certain embodiments, the robotic arm is configured to be maneuveredto a desired position to align an axis defined by the surgicalinstrument guide at a desired trajectory in relation to the vertebrae,wherein the dilator connected to the end effector of the robotic arm isautomatically positioned as the robotic arm is maneuvered to adjust tothe desired trajectory;

In certain embodiments, the dilator is configured to hold and/orrestrict movement of a surgical instrument therethrough.

In certain embodiments, the system includes a processor; and a memory,the memory storing instructions that, when executed by the processor,cause the processor to: store a transformation between the actualpatient anatomy and one or more medical images; determine an idealimplant trajectory; and provide, for display on a graphical userinterface, the ideal implant trajectory for review by the surgeon,wherein (i) the surgeon may adapt the ideal implant trajectory if neededusing hands-on planning, and (ii) the surgeon acknowledges the idealimplant trajectory or the adapted trajectory thereby causing theacknowledged trajectory to be stored as the desired trajectory.

In another aspect, the disclosed technology includes a robotic surgicalsystem for performing surgery, the system including: a robotic armcomprising a force and/or torque control end-effector, wherein theend-effector comprises a surgical tool holder attached to the roboticarm via a force sensor, wherein the surgical tool holder is sized andshaped to hold a surgical tool; an actuator for controlled movement ofthe robotic arm and/or positioning of the surgical tool holder; anavigation system for detection of (i) a position of a surgical toolheld by the robotic arm and (ii) patient position, the navigation systemincluding: a patient navigation marker associated a patient anatomy foridentifying the patient position, a robot navigation marker associatedthe surgical tool for identifying the surgical tool position, and atracking camera; a processor and a non-transitory computer readablemedium storing instructions thereon, wherein the instructions, whenexecuted, cause the processor to: determine one or more projectedtrajectories based on a position of a surgical tool according to a toolnavigation marker, a patient position according to a patient navigationmarker, and one or more patient medical images; provide, for display ona graphical user interface, the one or more projected trajectories;receive a selection of the desired trajectory from the one or moreprojected trajectories; assist a surgeon in bringing the surgical toolholder to the desired trajectory, wherein assisting the surgeon inbringing the surgical tool holder to the desired trajectory comprises atleast one of (i) and (ii): (i) providing attractive haptic feedback(e.g., force and/or torque) to guide the surgeon to bring the surgicaltool holder to the target position, and/or (ii) providing resistivehaptic feedback (e.g., force and/or torque) to resist movement of thesurgical tool holder in directions away from the desired trajectory; andafter the surgical tool holder is brought to the desired trajectory,lock the surgical tool holder along the desired trajectory.

In certain embodiments, the instructions, when executed by theprocessor, cause the processor to, prior to assisting a surgeon inbringing the surgical tool holder to the desired trajectory, detect, viaa sensor, the presence of a hand on a handle of the robotic arm.

In certain embodiments, the handle extends at least in part from therobotic arm.

In certain embodiments, the instructions to determine one or moreprojected trajectories comprises instructions that, when executed by theprocessor, cause the processor to: receive, from a navigation pointer,identification of a point along the patient anatomy; and determine theone or more projected trajectories based on the identified point alongthe patient anatomy.

In certain embodiments, receiving a selection of a desired trajectoryfrom the one or more projected trajectories comprises receiving amodified trajectory based at least in part on one of the one or moretrajectories, wherein the desired trajectory is the modified trajectory.

In certain embodiments, the instructions, when executed by theprocessor, cause the processor to, prior to receiving a selection of adesired trajectory from the one or more projected trajectories, renderand display a representation of the projected trajectory and at leastone of the one or more medical images.

In certain embodiments, the determination of the projected trajectoryand the rendering and display of the projected trajectory is updated asthe position of the surgical tool holder is changed, thereby providingvisual feedback to a user to assist the user in positioning the surgicaltool holder at a desired position.

In certain embodiments, the instructions, when executed by theprocessor, cause the processor to, prior to locking the surgical toolholder along the desired trajectory, detecting, via a force sensor, acollision between the surgical tool holder an another object.

In certain embodiments, the instructions, when executed by theprocessor, cause the processor to measure movement of the patientposition and move the surgical tool holder based on said measuredmovement.

In certain embodiments, the one or more medical images comprise one ormore of an MRI, CT, fluoroscopy, CT (ISO-C-3D) or 3D fluoroscopy medicalimage.

In certain embodiments, the one or more medical images comprise at leastone of a pre-operative or an intra-operative medical image.

In certain embodiments, registering the patient is performed by therobotic surgical system automatically based at least in part on apatient navigation marker attached to the patient anatomy, and the oneor more medical images.

In certain embodiments, registering the patient is performed using atleast one or manual point-to-point registration, surface matching, andfluoroscopy-based registration.

In certain embodiments, the instructions to provide, for display on agraphical user interface, the one or more projected trajectoriescomprise instructions to provide a list of trajectories, for display ona graphical user interface, the one or more projected trajectories.

In certain embodiments, the instructions to provide, for display on agraphical user interface, the one or more projected trajectoriescomprise instructions to provide a preview of at least one of the one ormore trajectories with the at least one of the one or more patientmedical images.

In certain embodiments, the system includes a mobile cart that permitsthe robotic surgical system to be moved in and out of the operatingroom, wherein the mobile cart comprises a plurality of wheels for movingthe robotic surgical system and a plurality of rigid legs on which themobile cart sits to stabilize the robotic surgical system on anoperating room floor, wherein either the plurality of wheels or theplurality of rigid legs are retractable.

In certain embodiments, the system includes a handle extending from theend effector that may be grasp by a hand of a user to move and/orposition the end effector—with at least four degrees of freedom.

In certain embodiments, force sensor located between the robotic arm andthe tool holder for measuring forces and/or torques applied by a user tothe first surgical tool held by the tool holder.

In certain embodiments, the system includes a sensor that detects thepresence of the hand of the user on the handle.

In certain embodiments, during an operation the end-effector is onlymoved by the robotic surgical system when the sensor detects the hand ofthe user on the handle, thereby reducing the likelihood that theend-effector is moved unintentionally.

In another aspect, the disclosed technology includes a method ofperforming surgery with a robotic surgical system, the method including:determining, by a processor of a computing device, one or more projectedtrajectories based on a position of a surgical tool holder according toa tool navigation marker, a patient position according to a patientnavigation marker, and one or more patient medical images; providing, bythe processor, for display on a graphical user interface, the one ormore projected trajectories; receiving, by the processor, a selection ofthe desired trajectory from the one or more projected trajectories;assisting, by the processor, a surgeon in bringing the surgical toolholder to the desired trajectory, wherein assisting the surgeon inbringing the surgical tool holder to the desired trajectory comprises atleast one of (i) and (ii): (i) providing attractive haptic feedback(e.g., force and/or torque) to guide the surgeon to bring the surgicaltool holder to the target position, and/or (ii) providing resistivehaptic feedback (e.g., force and/or torque) to resist movement of thesurgical tool holder in directions away from the desired trajectory; andafter the surgical tool holder is brought to the desired trajectory,locking, by the processor, the surgical tool holder along the desiredtrajectory.

In certain embodiments, the method includes, prior to assisting asurgeon in bringing the surgical tool holder to the desired trajectory,detecting, by the processor, via a sensor, the presence of a hand on ahandle of the robotic arm.

In certain embodiments, the handle extends at least in part from therobotic arm.

In certain embodiments, the method includes determining one or moreprojected trajectories includes: receiving, by the processor, from anavigation pointer, identification of a point along the patient anatomy;and determining, by the processor, the one or more projectedtrajectories based on the identified point along the patient anatomy.wherein a selection of a desired trajectory from the one or moreprojected trajectories comprises receiving a modified trajectory basedat least in part on one of the one or more trajectories, wherein thedesired trajectory is the modified trajectory.

In certain embodiments, the method includes registering the patient,wherein registering the patient comprises determining a transformationbetween a patient anatomy and one or more medical images.

In certain embodiments, the method includes, prior to receiving aselection of a desired trajectory from the one or more projectedtrajectories, rendering and displaying a representation of the projectedtrajectory and at least one of the one or more medical images.

In certain embodiments, the determination of the projected trajectoryand the rendering and display of the projected trajectory is updated asthe position of the surgical tool holder is changed, thereby providingvisual feedback to a user to assist the user in positioning the surgicaltool holder at a desired position.

In certain embodiments, the method includes, prior to locking thesurgical tool holder along the desired trajectory, detecting, via aforce sensor, a collision between the surgical tool holder an anotherobject.

In certain embodiments, the method includes measuring movement of thepatient position and move the surgical tool holder based on saidmeasured movement.

In certain embodiments, the one or more medical images comprise one ormore of an MRI, CT, fluoroscopy, CT (ISO-C-3D) or 3D fluoroscopy medicalimage.

In certain embodiments, the one or more medical images comprise at leastone of a pre-operative or an intra-operative medical image.

In certain embodiments, registering the patient is performed by therobotic surgical system automatically based at least in part on apatient navigation marker attached to the patient anatomy, and the oneor more medical images.

In certain embodiments, registering the patient is performed using atleast one or manual point-to-point registration, surface matching, andfluoroscopy-based registration.

In certain embodiments, the method includes providing, for display on agraphical user interface, the one or more projected trajectoriescomprises providing a list of trajectories, for display on a graphicaluser interface, the one or more projected trajectories.

In certain embodiments, providing, for display on a graphical userinterface, the one or more projected trajectories comprises providing apreview of at least one of the one or more trajectories with the atleast one of the one or more patient medical images.

In certain embodiments, the method includes moving a mobile carttransporting the robotic surgical system in proximity to an operatingtable; and stabilizing the mobile cart.

In certain embodiments, the method includes preventing, by theprocessor, movement of the end-effector unless a sensor on a handle ofthe robotic arm detects a hand of a user on the handle, thereby reducingthe likelihood that the end-effector is moved unintentionally.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing and other objects, aspects, features, and advantages ofthe present disclosure will become more apparent and better understoodby referring to the following description taken in conjunction with theaccompanying drawings, in which:

FIG. 1 is a diagram of an operating room in which a mobile cart housinga robotic system for a robotic-assisted spinal surgical procedure ispositioned, in accordance with various embodiments of the disclosedtechnology;

FIGS. 2A-B are illustrations of an example set of dilators used forperforming a minimally invasive surgical procedure;

FIG. 3 is an illustration of an example robotic surgical system using adilator;

FIG. 4 is an illustration of an example robotic surgical system forperforming minimally invasive surgery using a guided dilator;

FIG. 5 is a flowchart of an example method of performing minimallyinvasive spinal surgery with a robotic surgical system;

FIG. 6 is a flowchart of an example method for performing minimallyinvasive surgery using minimally invasive surgical techniques;

FIG. 7 is a flowchart of an example method for performing minimallyinvasive surgery using minimally invasive surgical techniques;

FIG. 8 is an illustration of an example dilator fixation for attaching adilator to a robotic arm;

FIG. 9 is an illustration of a system for robotic integration withautomatic planning;

FIG. 10 illustrates a flow chart of a method 1000 of performingminimally invasive surgery using automatic planning;

FIG. 11 shows a block diagram of an exemplary cloud computingenvironment; and

FIG. 12 is a block diagram of a computing device and a mobile computingdevice.

The features and advantages of the present disclosure will become moreapparent from the detailed description set forth below when taken inconjunction with the drawings, in which like reference charactersidentify corresponding elements throughout. In the drawings, likereference numbers generally indicate identical, functionally similar,and/or structurally similar elements.

DETAILED DESCRIPTION OF THE EMBODIMENTS

FIG. 1 illustrates an example surgical robotic system in an operatingroom 100. In some implementations, one or more surgeons, surgicalassistants, surgical technologists and/or other technicians, (106 a-c)perform an operation on a patient 104 using a robotic-assisted surgicalsystem. One or more dilators may be used with the robotic surgicalsystem to perform a minimally invasive surgery. The dilators may be usedto provide a working channel through which the operation is performed.Standard dilators may be used with a robotic surgical system to provideprecise guidance of surgical tools. A dilator may be held by the robotand automatically repositioned when the surgeon adjusts a trajectory forperforming the surgery. The dilator itself may be used as a surgicalinstrument guide along with dilator adaptors that adjust the diameter ofa portion of the dilator to allow for different sized tools to be guidedby the dilator. Surgical instrument guides may also be held by therobotic arm such that tools are guided by a surgical instrument guidethrough the dilator to perform a medical procedure.

For example, first dilator may be used to access a vertebrae of apatient through the patient's muscles and skin. Subsequent dilators areconfigured to be positioned over the preceding dilators and increase thesize of the working channel. Each dilator except the last added dilatoris configured to be removed from the patient thereby leaving the lastadded dilator. The last added dilator is configured to be attached to anend effector of a robotic arm using a dilator fixator. In anotherexample, the dilator inserted into the patient may be designed to expandthereby increasing the diameter of the working channel without addingadditional dilators.

A manipulator is configured to allow robotically-assisted or unassistedpositioning and/or movement of the last added dilator by a user with atleast four degrees of freedom to align an axis defined by the last addeddilator with respect to the vertebrae. Adjustment of the manipulatorautomatically adjusts an angle and/or position of the attached dilatorwith respect to the vertebrae and aligns an axis defined by the attacheddilator with a desired trajectory during a surgical procedure withoutremoval of the attached dilator from the patient tissue during therepositioning.

In some implementations, the surgical robotic system includes a surgicalrobot 102 on a mobile cart. The surgical robot 102 may be positioned inproximity to an operating table 112 without being attached to theoperating table, thereby providing maximum operating area and mobilityto surgeons around the operating table and reducing clutter on theoperating table. In alternative embodiments, the surgical robot (orcart) is securable to the operating table. In certain embodiments, boththe operating table and the cart are secured to a common base to preventany movement of the cart or table in relation to each other, even in theevent of an earth tremor.

In some implementations, the footprint of the mobile cart is small (forexample, no greater than 682 millimeters by 770 millimeters), therebypermitting improved access by a surgeon of both sides of an operatingtable at which the mobile cart is positioned during an operation.

The mobile cart may permit a user (operator) 106 a, such as atechnician, nurse, surgeon, or any other medical personnel in theoperating room, to move the surgical robot 102 to different locationsbefore, during, and/or after a surgical procedure. The mobile cartenables the surgical robot 102 to be easily transported into and out ofthe operating room 100. For example, a user 106 a may move the surgicalrobot into the operating room from a storage location. In someimplementations, the mobile cart may include wheels, a track system,such as a continuous track propulsion system, or other similar mobilitysystems for translocation of the cart. The mobile cart may include anattached or embedded handle for locomotion of the mobile cart by anoperator.

In some implementations, the wheels include a locking mechanism thatprevents the cart from moving. The stabilizing, braking, and/or lockingmechanism may be activated when the machine is turned on. In someimplementations, the mobile cart includes multiple stabilizing, braking,and/or locking mechanisms. In some implementations, the stabilizingmechanism is electro-mechanical with electronic activation. Thestabilizing, braking, and/or locking mechanism(s) may be entirelymechanical. The stabilizing, braking, and/or locking mechanism(s) may beelectronically activated and deactivated.

In some implementations, the surgical robot 102 includes a robotic armmounted on a mobile cart. An actuator may move the robotic arm. Therobotic arm may include a force control end-effector configured to holda surgical tool. The robot may be configured to control and/or allowpositioning and/or movement of the end-effector with at least fourdegrees of freedom (e.g., six degrees of freedom, three translations andthree rotations).

In some implementations, the robotic arm is configured to releasablyhold a surgical tool, allowing the surgical tool to be removed andreplaced with a second surgical tool. The system may allow the surgicaltools to be swapped without re-registration, or with automatic orsemi-automatic re-registration of the position of the end-effector.Registration spatially aligns the robot, patient (e.g., spine) and thedesired trajectory. A marker may be coupled or associated with avertebrae or other bone to assist with the registration process. Thelocation of the marker is determined by the system. The system storesthis position. The position of the vertebrae is thus known. The positionof other bones may also be determined with reference to the marker. Oncethe registration is complete, tracking and/or immobilization ensure thatthe registration (e.g., spatial orientation) is maintainedImmobilization typically fixes the patient or bone (e.g., spine) withrespect to the robot. In contrast, tracking system tracks the positionof the patient or the bone (e.g., by tracking the movement of the markeror position of the marker relative to the robot) as described inrelation to FIGS. 1 and 3.

In some implementations, the surgical robot 102 includes a robotic armcomprising joints allowing the arm to be automatically positioned uponuser command into various different predetermined configurationsconvenient for various preparatory, readying, and storage procedures.For example, the surgical robot 102 may be arranged in a standbyconfiguration. In a standby configuration, the robotic arm of surgicalrobot 102 may be arranged in a compacted standby configuration that, forexample, facilitates easy and compact storage of surgical robot 102 whenit is not in use. Other configurations may include a drape configurationin which the robot arm is extended to facilitate placement of a sterilesurgical drape over the robot and cart, and a preparation configurationin which the robot arm is positioned prior to movement to the operatingtable whereupon more precise movement of the robot arm will be performedfor alignment of the trajectory of the end effector (surgical toolholder).

In some implementations, the surgical system includes a surgical robot102, a tracking detector 108 that captures the position of the patientand different components of the surgical robot 102, and a display screen110 that displays, for example, real time patient data and/or real timesurgical robot trajectories.

In some implementations, when the surgical robot 102 is powered on,robot 102 switches from the standby configuration to anotherconfiguration, e.g., a preparation configuration. In someimplementations, preset positions of the robotic arm and the arrangementof each moveable portion of the robotic arm of surgical robot 102 may bestored in a memory of the surgical system.

In some implementations, the mobile cart includes a power source forpowering the robotic system, including, for example, the actuator. Thepower source may include a battery and/or a battery backup. In someimplementations, the mobile cart is charged and/or powered by anelectrical socket in the operating room. The mobile cart may be capableof being powered by a battery on the cart and/or via an electricaloutlet. In some implementations, power is provided via an electricaloutlet during the surgical procedure. A battery may be used to providepower to the system when the system is being moved or in case of a powercut.

In some implementations, different elements of the surgical system workin tandem by communicating with each other wirelessly. In someimplementations, a tracking detector 108 monitors the location ofpatient 104 and the surgical robot 102. The tracking detector may be acamera, a video camera, an infrared detector, field generator andsensors for electro-magnetic tracking or any other motion detectingapparatus. In some implementation, based on the patient and robotposition, the display screen displays a projected trajectory and/or aproposed trajectory for the robotic arm of robot 102 from its currentlocation to a patient operation site. By continuously monitoring thepatient and robotic arm positions, using tracking detector 108, thesurgical system can calculate updated trajectories and visually displaythese trajectories on display screen 110 to inform and guide surgeonsand/or technicians in the operating room using the surgical robot. Inaddition, in certain embodiments, the surgical robot 102 may also changeits position and automatically position itself based on trajectoriescalculated from the real time patient and robotic arm positions capturedusing the tracking detector 108. For instance, the trajectory of theend-effector can be automatically adjusted in real time to account formovement of the vertebrae or other part of the patient during thesurgical procedure.

For safety reasons, the mobile cart is provided with a stabilizationsystem that may be used during a surgical procedure performed with asurgical robot. The stabilization mechanism increases the globalstiffness of the mobile cart relative to the floor in order to ensurethe accuracy of the surgical procedure. An example of the roboticsurgical system discussed and used herein is described in U.S. patentapplication Ser. No. 14/266,769, filed Apr. 30, 2014, entitled“Apparatus, Systems, and Methods for Precise Guidance of SurgicalTools,” which is hereby incorporated by reference in its entirety.

FIGS. 2A-B are illustrations of an example set of dilators 202 used forperforming a minimally invasive surgical procedure. Dilators 202 may beused to achieve a working channel for surgical instruments. The dilatorsmay be inserted manually by a surgeon one by one until the surgeonobtains the required diameter of the working channel. For example, afirst dilator 202 a may be inserted at the access point. The firstdilator 202 may be a hollow tube-like device (similar to the otherdilators 202 b-d) or it may be a solid tube-like device for marking theaccess point. The second dilator 202 b maybe added over the firstdilator 202 a. Similarly, the third dilator 202 c may be added over thesecond dilator 202 b to further increase the size of the workingchannel. Each dilator added after the first dilator 202 a increases thesize of the working channel. In this example, the fourth dilator 202 dis added over the third dilator 202 c. In some implementations, dilatorsmay be removed after the next dilator is added. For example, the seconddilator 202 b may be removed after the third dilator 202 c is added. Insome implementations, dilators may be removed after the last dilator isadded. For example, previously added dilators may be removed after thelast dilator 202 d is added, thereby leaving a working channel thediameter of the forth dilator 202 d.

The dilators may be used with a robotic surgical system, for example, asshown in FIG. 3. FIG. 3 is an illustration of an example roboticsurgical system 300 using a dilator 314. The surgeon may manually obtainaccess to the vertebrae 302 through the skin and muscles. After applyingthe dilators as described in relation to FIGS. 2A-B, the internaldilators may be removed, leaving the largest one 314. The robot 306 maybe moved closer to the patient and attached to the dilator 314 using thedilator fixation 304. In some implementations, a tool guide 310 held bya tool holder 312 fits inside the dilator 314. The tool guide 310 may beused to guide a surgical instrument 308 to access the vertebrae 302 viathe working channel formed by the dilator 314. For example, the toolguide 310 may be used to prepare a hole in vertebrae of a patient. Thetool holder 312 may be attached to the may be attached to the robot 306via a tool holder attachment 316. In some implementations, the dilator314 itself acts as a tool guide.

In some implementations, standard dilators may be used with the roboticsurgical system to provide a precise solution to guide surgical tools.For example, in contrast to surgeries using passive arms to hold thedilator, the dilator may be held by the robotic surgical system and thedilator may be automatically repositioned in response to the surgeonchanging the trajectory 318.

A manipulator of the robotic surgical system is configured to allowrobotically-assisted or unassisted positioning and/or movement of thedilator attached to the end effector (e.g., the last added dilator) by auser with at least four degrees of freedom to align an axis defined bythe dilator attached to the end effector with respect to the vertebrae.The robotic arm is configured to be maneuvered to a desired position toalign an axis defined by the surgical instrument guide at a desiredtrajectory in relation to the vertebrae. The dilator connected to theend effector of the robotic arm is automatically positioned as therobotic arm is maneuvered to adjust to the desired trajectory.Adjustment of the manipulator automatically adjusts an angle and/orposition of the attached dilator with respect to the vertebrae andaligns an axis defined by the attached dilator with a desired trajectoryduring a surgical procedure without removal of the attached dilator fromthe patient tissue during the repositioning.

FIG. 4 is an illustration of an example robotic surgical system forperforming a minimally invasive surgery using a guided dilator. Thesurgeon may manually obtain access to the vertebrae 402 through the skinand muscles. After applying the dilators as described in relation toFIGS. 2A-B, the internal dilators may be removed, leaving the largestone 408. The robot 406 may be moved closer to the patient and attachedto the dilator 408 using the dilator fixation 404. The dilator 408 isdesigned to guide a surgical tool 412. A dilator adapter 410 may be usedto allow different size tools to be used with the dilator 408.

In some implementations, standard dilators may be used with the roboticsurgical system to provide a precise solution to guide surgical tools.For example, in contrast to surgeries using passive arms to hold thedilator, the dilator may be held by the robotic surgical system and thedilator may be automatically repositioned in response to the surgeonchanging the trajectory 414.

FIG. 5 is a flowchart of an example method 500 of performing minimallyinvasive spinal surgery with a robotic surgical system. In someimplementations, the method may include positioning a mobile cart (502)transporting a robotic surgical system. The robotic surgical system mayinclude a robotic arm in proximity to an operating table. The roboticarm may have an end effector. After positioning the mobile cart, themobile cart may be stabilized (504).

The method 500 may include maneuvering a dilator to access a vertebraeof a patient through the patient's muscles and skin (506). The dilatormay define a working channel for accessing the vertebrae. Additionaldilators may be placed over earlier placed dilator(s) (508) to increasethe size of the working channel. All dilators except the last addeddilator may be removed (510) thereby leaving a working channel of adesired diameter for the surgery.

For example, a second dilator may be maneuvered to slide over thedilator. The second dilator may be sized and shaped to slide over thedilator and increase the size of the working channel. After positioningthe second dilator over the dilator (and/or after positioning one ormore subsequent dilators over the preceding dilators), the dilator(and/or other dilators except the final added dilator) may be removedfrom the patient, thereby leaving the last added dilator.

The method 500 may include attaching a dilator to the end effector ofthe robotic arm using a dilator fixator (512). In some implementations,the dilator attached (or to be attached) to the end effector is thedilator with largest circumference. Following attachment of the dilatorto the end effector, the end effector may be repositioned to adjust theangle and/or position of the attached dilator with respect to thevertebrae (514). The robotic arm may be maneuvered to a desired positionto align an axis defined by the surgical instrument guide at a desiredtrajectory in relation to the vertebrae. This causes the dilatorconnected to the end effector of the robotic arm to be automaticallypositioned as the robotic arm is maneuvered to adjust to the desiredtrajectory.

In some implementations, a surgical instrument guide is placed inside ofthe dilator attached (or to be attached) to the end effector. Thesurgical instrument guide (e.g., drill bit guide, tap guide, screwdriverguide, screw guide, awl guide, and implant guide) is sized and shaped tofit at least partially inside the dilator along an axis defined by thedilator and is configured to hold and/or restrict movement of a surgicalinstrument (e.g., drill bit, pedicle finder, screw-based implant, awl,surface-pointing device, screw based implant, screw driver, tap,implants, implants with extenders, or other similar instruments)therethrough. The surgical instrument may be, for example, a tap such asthe StealthStation® CR Horizon Legacy Taps from Medtronic, Inc. ofMinneapolis, Minn. or a universal surgical tools system (e.g.,Medtronic's NavLock system). In some implementations, the dilator itselfis used as a surgical instrument guide. The dilator may be configured tohold and/or restrict movement of a surgical instrument therethrough.Dilator adapters may be used to allow different size instruments to beguided by the dilator.

FIG. 6 is a flowchart of an example method 600 for performing minimallyinvasive surgery. In some implementations, the method may includepositioning a mobile cart (602) transporting a robotic surgical system.The robotic surgical system may include a robotic arm in proximity to anoperating table. The robotic arm may have an end effector. Afterpositioning the mobile cart, the mobile cart may be stabilized (604).

The method 600 may include maneuvering a dilator to access a vertebraeof a patient through the patient's muscles and skin (606). The dilatormay define a working channel for accessing the vertebrae. The diameterof the working channel of the dilator may be expanded (608). Forexample, the dilator may be configured such that the diameter of thedilator may be increased. Thus, the size of the working channel may beincreased without the use of multiple dilators.

The method 600 may include attaching the dilator to the end effector ofthe robotic arm using a dilator fixator (610). Following attachment ofthe dilator to the end effector, the end effector may be repositioned toadjust the angle and/or position of the attached dilator with respect tothe vertebrae (612).

FIG. 7 is a flowchart of an example method 700 for performing minimallyinvasive surgery using minimally invasive surgical techniques. In someimplementations, the method may include positioning a mobile cart (702)transporting a robotic surgical system. The robotic surgical system mayinclude a robotic arm in proximity to an operating table. The roboticarm may have an end effector. After positioning the mobile cart, themobile cart may be stabilized (704).

The method 700 may include registering the patient (706). Registeringthe patient may include identifying the transformation between theactual patient anatomy and one or more medical images. Registering thepatient may include identifying a correlation between the surgicalanatomy of the patient in the “real world” and a medical image (e.g., animage acquisition during surgery). Registration may also be accomplishedusing co-registration (e.g., former studies). The robotic arm may bemaneuvered towards the vertebrae on which the surgeon will operate(708). In some implementations, the robotic surgical system willrecognize the vertebra on which the surgeon wishes to operate as therobotic arm is maneuvered towards the vertebra. A processor of acomputing device may determine an ideal implant trajectory (710). Thesystem allows for a desired trajectory (e.g., for a drill guide duringspinal surgery) to be set in a variety of manners based on thecircumstances of the surgery. For example, some surgical procedures areplanned pre-operatively with the surgeon defining the desired positionof an implant using imaging technology, such as CT images (e.g., 3D CTimages). The desired position of the implant may also be determined andproposed by the system. In the operating room the surgeon may be guidedby the robotic system (e.g., robotic guidance of the surgical tools) toaccurately execute the planning.

The ideal implant trajectory may be displayed on a graphical userinterface for review by the surgeon (712). The surgeon may adapt theideal implant trajectory if needed using hands-on planning. The surgeonacknowledges the ideal implant trajectory or the adapted trajectorythereby causing the acknowledged trajectory to be stored as the desiredtrajectory.

The method 700 may include maneuvering a dilator to access a vertebraeof a patient through the patient's muscles and skin (714). The dilatormay define a working channel for accessing the vertebrae. The diameterof the working channel may be expanded (716) using the techniques asdescribed in relation to FIGS. 5 and 6. The method 700 may includeattaching the dilator to the end effector of the robotic arm using adilator fixator (718). Following attachment of the dilator to the endeffector, the end effector may be repositioned to adjust the angleand/or position of the attached dilator with respect to the vertebrae(720).

Having described various embodiments of the disclose technology, it willnow become apparent to one of skill in the art that other embodimentsincorporating the concepts may be used. It is felt, therefore, thatthese embodiments should not be limited to the disclosed embodiments,but rather should be limited only by the spirit and scope of thefollowing claims.

FIG. 8 is an illustration of an example dilator fixation 802 forattaching a dilator 804 to a robotic arm 806. The dilator fixation 802may be mechanically coupled to the robotic arm 806 such that the dilatorfixation is rigidly coupled to the robotic arm 806. For example, thedilator fixation 802 maybe bolted to the robotic arm 806 such that thedilator fixation 802 will not move relative to the robotic arm 806thereby allowing the robot to always knows the position of the dilatorfixation 802. The dilator fixation 802 may provide a quick-releasemechanism to rigidly secure the dilator 804 to the robotic arm 806. Insome implementations, the dilator 804 and dilator fixation 802 areformed as one piece and attached to the robotic arm 806 via a bolt,screw, or quick-release mechanism. The attachment system may be designedsuch that the dilator 804 may be removed quickly and easily (e.g.,toollessly).

FIG. 9 is an illustration of a system for robotic integration withautomatic planning, for example, as described in relation to FIG. 10.The system, in certain embodiments, includes a robot arm 901, a patientvertebrae 902 (e.g., with a patient navigation marker 910 attached), arobot tool holder with tool guide 903, a robot navigation marker 904, atracking camera 906, a connection to the tracking camera 907, anavigation system 908, and a connection to robot-navigation 905. Incertain embodiments, a navigations marker, such as patient navigationmarker or robot navigation marker 904, is a rigid body with reflectivespheres which is attached to an item, such as a robot end effector orpatient vertebrae. A navigation system or tracker measures positions ofeach sphere using stereoscopic cameras and triangulation. By assemblingthe positions of spheres together with marker geometry, the translationand rotation of the marker in space is known. After the process ofregistration the system knows the location of the marked item, such asthe end-effector or patient vertebrae in reference to the marker thus bytracking the marker or patient frame we know where the marked item islocated.

FIG. 10 illustrates a flow chart of a method 1000 of performingminimally invasive surgery using automatic planning. In certainembodiments, automatic planning includes obtaining patient medicalimages (1002). In this step (1002) medical images of the patient areobtained. These medical images can come from MRI, CT, fluoroscopy, CT(ISO-C-3D, such as Siemens ISO-C 3D C-Arm) or 3D fluoroscopy (e.g.,0-Arm Surgical Imaging System by Medtronic, Inc. of Minneapolis, Minn.,the Artis Zeego by Siemens Medical Solutions USA, Inc. of Malvern, Pa.).The images can be obtained pre-operatively, as it is often the case forMRI or CT, or intra-operatively which is the case for fluoroscopy and 3Dfluoroscopy.

Next, the patient is registered (1004). Registration is accomplished byfinding the transformation between actual patient anatomy and medicalimages. This can be done automatically for intra-operative medicalimaging. In this case the patient navigation marker 910 is attached tothe vertebrae 902 before images are taken. A similar patient navigationmarker 910 is attached to the medical imaging device. The patientnavigation marker 910 is recognized by the software on the images and byknowing the position of imaging device, medical images can be related tothe position of the patient navigation marker 910 for further usage.

There are several alternative approaches for registering the patient andthese include manual point-to-point registration, surface matching, andfluoroscopy-based registration (e.g., intraoperative fluoroscopic imagesare matched to pre-operative CT images).

Next, a trajectory to operate on is selected (1006). Planning of thetrajectory can come from different sources. It can be preparedpre-operatively by the surgeon, his assistant, external company, orother parties.

For certain systems the trajectory can be planned automatically based onmedical images. An automatic planning algorithm takes these medicalimages as an input and based on these medical images it recognizes thevertebrae and proposes the most suitable trajectories (e.g. a singletrajectory or multiple trajectories, each of which may be a viableoption).

In this step (1006) the surgeon identifies for the system whichvertebra(e) he/she would like to operate on. This can be accomplished ina variety of manners, including the presentation of the list oftrajectories (e.g., on a display) for selection by the surgeon. Incertain embodiments, the user is able to preview trajectories on medicalimages and based on these decide which trajectory to use.

An alternative way of selecting the trajectory is based on user pointingthe actual patient vertebrae and the system automatically presenting thetrajectory/trajectories located the closest to this place. This providesa very intuitive and user friendly approach. The user can use variousmeans for indicating the vertebrae/surgical spot he/she would like tooperate on. For example, the user can use robotic arm whose position isknown to the system. The user can use any navigated surgical instrumentas well, including a navigation pointer, navigated screwdriver,navigated drill, as well as other device. In this embodiment, the systemautomatically “discovers” or “guesses” the intention of the surgeon andpresents him the best option for the trajectory to the surgeon.

Next, the surgeon reviews, corrects (if applicable) and approves thetrajectory (1008). The surgeon, in certain embodiments, has the abilityto review the trajectory. This can be accomplished by providing thesurgeon with medical images with a virtual projection of the trajectorythereon (e.g., on a display of the robotic surgical system). Typically asurgeon uses three medical views to review the trajectory (e.g.sagittal, axial and coronal view), but other views can be used as well(e.g., other views and more or less views).

In certain embodiments, the system provides a follow view that shows animage (e.g., animated image) following the trajectory in the viewperpendicular to the trajectory axis to make sure that there is enoughbony structures on each side for the trajectory to hold the implant.

In certain embodiments, the surgeon corrects the trajectory based on thereview. The trajectory can be corrected using hands-on planning mode. Adiscussion of hands on planning can be found in U.S. patent applicationSer. No. 14/266,769, filed Apr. 30, 2014, entitled “Apparatus, Systems,and Methods for Precise Guidance of Surgical Tools,” which is herebyincorporated by reference in its entirety. Alternatively, the trajectorycan be corrected using navigated instruments to point to a bettertrajectory, thereby correcting/replacing the previous trajectory.Alternatively, the trajectory can be corrected by redoing automaticplanning with different input parameters or manually defining trajectoryon the computer screen.

In certain embodiments, the surgeon is given the ability (direct, e.g.via acknowledgement button, or indirect, if surgeon proceeds, it meansthat he is OK) to approve the trajectory. In certain embodiments, themethod proceeds without the surgeon approving the trajectory.

Next, the robot arm 901 is brought to the trajectory (1010). Usually itis difficult for the surgeon to find the real trajectory in space whenshown only with the indications on the computer screen. In certainembodiments, the disclosed technology assist the surgeon in finding thetrajectory using the robot 901. This represents a great usabilityimprovement as it simplifying a user task, improves safety as the robotcan be more reliable than a human in spatial location, and improvesefficiency because robot can quicker find the trajectory than the userand thus save time in the operating room.

In certain embodiments, the robot can automatically move the trajectoryfollowing user request (e.g., and in certain embodiments, with usersupervision). However, automatic movement by the robot is dangerous inan operating room as typically the robot only has partial knowledge ofthe surrounding environment which makes collisions possible (andprobable as the operating room is highly unstructured environment). Assuch, the disclosed robot, in certain embodiments, is equipped in forcesensor. The force sensor can be used to discover/identify collisions byan increase of forces (e.g., if the force sensor is expecting to measureno force, the system can detect a collision if a force is detected).Similarly, additional sensors (e.g., artificial skin, laser scanner,electrical/capacitive proximity sensors, etc.) can be added on therobotic arm with a goal of detecting a collision. Upon detecting acollision, the robot shall react accordingly, such as stopping oradapting the trajectory of movement (e.g. move the robot arm segments upif these are the lower sensors detecting collision).

In some embodiments, rather than using automatic movement, the surgeonis required to move the robot “manually”, as in hands-on planning.However, the robot may still provide the surgeon with assistance infinding the trajectory by providing haptic feedback (e.g., force and/ortorque). This assistance can be provided by simulating attractiveforces/torques to guide the surgeon to bring the robot to the targetposition. In certain embodiments, these forces/torques make it easier tomove to the direction of correct trajectory while preventing/makingdifficult to move in the other direction (e.g., the latter, by providingresistive forces). For example, spring-like forces (proportional to thedistance) or magnetic-like forces (proportional to square of thedistance) may be used to guide the user to the trajectory. The hapticfeedback may be delivered to the user (e.g., surgeon) by an actuatorassociated with the robotic arm, controlled by a processor. The amount(intensity) of force feedback to be delivered to the user may becomputed in real-time as a function of the position of the robotic armin relation to the computed correct trajectory. The haptic feedback maybe computed and delivered in relation to a haptic guide, where thehaptic guide provides constraints to particular regions, points, and/orsurfaces, or the haptic guide may provide detents or force fields toencourage movement toward a particular position in 3D space at aparticular orientation (yaw, pitch, roll).

Once the robot is along the correct trajectory, it can be locked to it.In certain embodiments, the user is allowed to move the end effectoronly along the trajectory (e.g., if it is a line in space) or rotatealong trajectory if the rotation of the tool is not important. Incertain embodiments, when user tries to move out of the trajectory,he/she feels repulsive forces preventing him/her from doing so.

The surgeons shall know when he/she is precisely (or with certainpre-defined error margin) along the trajectory. It can be implementedusing visual feedback, such as a green light interface when precisioncan be assured and/or an alarm when the surgeon moves out of thetrajectory (e.g., audible alarm).

In certain embodiments, once positioned along the trajectory, the robotmight come out of align with the trajectory, for example, due tomovement of the patient (e.g., breathing), forces applied to thevertebrae, or movement of the whole table. In this case, the appropriatemode may be activated to provide assistance in finding the trajectoryagain to lock the robot into the correct, new trajectory. In certainembodiments, the movement (e.g., of the patient or table) is measuredand the robot reacts to the movement automatically (e.g., the systemtracks the vertebra(e)). For example, the robot, in certain embodiments,provides real-time compensation to follow the movement of thevertebra(e). A discussion of tracking of the vertebrae is provided inU.S. patent application Ser. No. 14/522,509, filed Oct. 23, 2014,entitled “Robotic System and Method for Spinal and Other Surgeries,”which is hereby incorporated by reference in its entirety, and U.S.patent application Ser. No. 14/266,769, filed Apr. 30, 2014, entitled“Apparatus, Systems, and Methods for Precise Guidance of SurgicalTools.”

Next, the operation is performed (1012). This may include drilling ahole and inserting an implant in the hole, as well as other steps. Adiscussion of performing the operation using a surgical robot isdescribed in U.S. patent application Ser. No. 14/266,769, filed Apr. 30,2014, entitled “Apparatus, Systems, and Methods for Precise Guidance ofSurgical Tools.”

As explained below, steps for any method discussed herein can be done ina different order. For example, the robotic arm 901 can be brought tothe trajectory (e.g., step 1010 in FIG. 10) before reviewing,correcting, and approving the trajectory (e.g., step 1008 in FIG. 10).For example, if a surgeon wants to use the robot to correct thetrajectory plan, the robotic arm 901 may be brought to the trajectorybefore correcting the trajectory.

As shown in FIG. 11, an implementation of a network environment 1100 foruse in performing minimally invasive surgical techniques is shown anddescribed. In brief overview, referring now to FIG. 11, a block diagramof an exemplary cloud computing environment 1100 is shown and described.The cloud computing environment 1100 may include one or more resourceproviders 1102 a, 1102 b, 1102 c (collectively, 1102). Each resourceprovider 1102 may include computing resources. In some implementations,computing resources may include any hardware and/or software used toprocess data. For example, computing resources may include hardwareand/or software capable of executing algorithms, computer programs,and/or computer applications. In some implementations, exemplarycomputing resources may include application servers and/or databaseswith storage and retrieval capabilities. Each resource provider 1102 maybe connected to any other resource provider 1102 in the cloud computingenvironment 1100. In some implementations, the resource providers 1102may be connected over a computer network 1108. Each resource provider1102 may be connected to one or more computing device 1104 a, 1104 b,1104 c (collectively, 1104), over the computer network 1108.

The cloud computing environment 1100 may include a resource manager1106. The resource manager 1106 may be connected to the resourceproviders 1102 and the computing devices 1104 over the computer network1108. In some implementations, the resource manager 1106 may facilitatethe provision of computing resources by one or more resource providers1102 to one or more computing devices 1104. The resource manager 1106may receive a request for a computing resource from a particularcomputing device 1104. The resource manager 1106 may identify one ormore resource providers 1102 capable of providing the computing resourcerequested by the computing device 1104. The resource manager 1106 mayselect a resource provider 1102 to provide the computing resource. Theresource manager 1106 may facilitate a connection between the resourceprovider 1102 and a particular computing device 1104. In someimplementations, the resource manager 1106 may establish a connectionbetween a particular resource provider 1102 and a particular computingdevice 1104. In some implementations, the resource manager 1106 mayredirect a particular computing device 1104 to a particular resourceprovider 1102 with the requested computing resource.

FIG. 12 shows an example of a computing device 1200 and a mobilecomputing device 1250 that can be used to implement the techniquesdescribed in this disclosure. The computing device 1200 is intended torepresent various forms of digital computers, such as laptops, desktops,workstations, personal digital assistants, servers, blade servers,mainframes, and other appropriate computers. The mobile computing device1250 is intended to represent various forms of mobile devices, such aspersonal digital assistants, cellular telephones, smart-phones, andother similar computing devices. The components shown here, theirconnections and relationships, and their functions, are meant to beexamples only, and are not meant to be limiting.

The computing device 1200 includes a processor 1202, a memory 1204, astorage device 1206, a high-speed interface 1208 connecting to thememory 1204 and multiple high-speed expansion ports 1210, and alow-speed interface 1212 connecting to a low-speed expansion port 1214and the storage device 1206. Each of the processor 1202, the memory1204, the storage device 1206, the high-speed interface 1208, thehigh-speed expansion ports 1210, and the low-speed interface 1212, areinterconnected using various busses, and may be mounted on a commonmotherboard or in other manners as appropriate. The processor 1202 canprocess instructions for execution within the computing device 1200,including instructions stored in the memory 1204 or on the storagedevice 1206 to display graphical information for a GUI on an externalinput/output device, such as a display 1216 coupled to the high-speedinterface 1208. In other implementations, multiple processors and/ormultiple buses may be used, as appropriate, along with multiple memoriesand types of memory. Also, multiple computing devices may be connected,with each device providing portions of the necessary operations (e.g.,as a server bank, a group of blade servers, or a multi-processorsystem).

The memory 1204 stores information within the computing device 1200. Insome implementations, the memory 1204 is a volatile memory unit orunits. In some implementations, the memory 1204 is a non-volatile memoryunit or units. The memory 1204 may also be another form ofcomputer-readable medium, such as a magnetic or optical disk.

The storage device 1206 is capable of providing mass storage for thecomputing device 1200. In some implementations, the storage device 1206may be or contain a computer-readable medium, such as a floppy diskdevice, a hard disk device, an optical disk device, or a tape device, aflash memory or other similar solid state memory device, or an array ofdevices, including devices in a storage area network or otherconfigurations. Instructions can be stored in an information carrier.The instructions, when executed by one or more processing devices (forexample, processor 1202), perform one or more methods, such as thosedescribed above. The instructions can also be stored by one or morestorage devices such as computer- or machine-readable mediums (forexample, the memory 1204, the storage device 1206, or memory on theprocessor 1202).

The high-speed interface 1208 manages bandwidth-intensive operations forthe computing device 1200, while the low-speed interface 1212 manageslower bandwidth-intensive operations. Such allocation of functions is anexample only. In some implementations, the high-speed interface 1208 iscoupled to the memory 1204, the display 1216 (e.g., through a graphicsprocessor or accelerator), and to the high-speed expansion ports 1210,which may accept various expansion cards (not shown). In theimplementation, the low-speed interface 1212 is coupled to the storagedevice 1206 and the low-speed expansion port 1214. The low-speedexpansion port 1214, which may include various communication ports(e.g., USB, Bluetooth®, Ethernet, wireless Ethernet) may be coupled toone or more input/output devices, such as a keyboard, a pointing device,a scanner, or a networking device such as a switch or router, e.g.,through a network adapter.

The computing device 1200 may be implemented in a number of differentforms, as shown in the figure. For example, it may be implemented as astandard server 1220, or multiple times in a group of such servers. Inaddition, it may be implemented in a personal computer such as a laptopcomputer 1222. It may also be implemented as part of a rack serversystem 1224. Alternatively, components from the computing device 1200may be combined with other components in a mobile device (not shown),such as a mobile computing device 1250. Each of such devices may containone or more of the computing device 1200 and the mobile computing device1250, and an entire system may be made up of multiple computing devicescommunicating with each other.

The mobile computing device 1250 includes a processor 1252, a memory1264, an input/output device such as a display 1254, a communicationinterface 1266, and a transceiver 1268, among other components. Themobile computing device 1250 may also be provided with a storage device,such as a micro-drive or other device, to provide additional storage.Each of the processor 1252, the memory 1264, the display 1254, thecommunication interface 1266, and the transceiver 1268, areinterconnected using various buses, and several of the components may bemounted on a common motherboard or in other manners as appropriate.

The processor 1252 can execute instructions within the mobile computingdevice 1250, including instructions stored in the memory 1264. Theprocessor 1252 may be implemented as a chipset of chips that includeseparate and multiple analog and digital processors. The processor 1252may provide, for example, for coordination of the other components ofthe mobile computing device 1250, such as control of user interfaces,applications run by the mobile computing device 1250, and wirelesscommunication by the mobile computing device 1250.

The processor 1252 may communicate with a user through a controlinterface 1258 and a display interface 1256 coupled to the display 1254.The display 1254 may be, for example, a TFT (Thin-Film-Transistor LiquidCrystal Display) display or an OLED (Organic Light Emitting Diode)display, or other appropriate display technology. The display interface1256 may comprise appropriate circuitry for driving the display 1254 topresent graphical and other information to a user. The control interface1258 may receive commands from a user and convert them for submission tothe processor 1252. In addition, an external interface 1262 may providecommunication with the processor 1252, so as to enable near areacommunication of the mobile computing device 1250 with other devices.The external interface 1262 may provide, for example, for wiredcommunication in some implementations, or for wireless communication inother implementations, and multiple interfaces may also be used.

The memory 1264 stores information within the mobile computing device1250. The memory 1264 can be implemented as one or more of acomputer-readable medium or media, a volatile memory unit or units, or anon-volatile memory unit or units. An expansion memory 1274 may also beprovided and connected to the mobile computing device 1250 through anexpansion interface 1272, which may include, for example, a SIMM (SingleIn Line Memory Module) card interface. The expansion memory 1274 mayprovide extra storage space for the mobile computing device 1250, or mayalso store applications or other information for the mobile computingdevice 1250. Specifically, the expansion memory 1274 may includeinstructions to carry out or supplement the processes described above,and may include secure information also. Thus, for example, theexpansion memory 1274 may be provided as a security module for themobile computing device 1250, and may be programmed with instructionsthat permit secure use of the mobile computing device 1250. In addition,secure applications may be provided via the SIMM cards, along withadditional information, such as placing identifying information on theSIMM card in a non-hackable manner.

The memory may include, for example, flash memory and/or NVRAM memory(non-volatile random access memory), as discussed below. In someimplementations, instructions are stored in an information carrier and,when executed by one or more processing devices (for example, processor1252), perform one or more methods, such as those described above. Theinstructions can also be stored by one or more storage devices, such asone or more computer- or machine-readable mediums (for example, thememory 1264, the expansion memory 1274, or memory on the processor1252). In some implementations, the instructions can be received in apropagated signal, for example, over the transceiver 1268 or theexternal interface 1262.

The mobile computing device 1250 may communicate wirelessly through thecommunication interface 1266, which may include digital signalprocessing circuitry where necessary. The communication interface 1266may provide for communications under various modes or protocols, such asGSM voice calls (Global System for Mobile communications), SMS (ShortMessage Service), EMS (Enhanced Messaging Service), or MMS messaging(Multimedia Messaging Service), CDMA (code division multiple access),TDMA (time division multiple access), PDC (Personal Digital Cellular),WCDMA (Wideband Code Division Multiple Access), CDMA2000, or GPRS(General Packet Radio Service), among others. Such communication mayoccur, for example, through the transceiver 1268 using aradio-frequency. In addition, short-range communication may occur, suchas using a Bluetooth®, Wi-Fi™, or other such transceiver (not shown). Inaddition, a GPS (Global Positioning System) receiver module 1270 mayprovide additional navigation- and location-related wireless data to themobile computing device 1250, which may be used as appropriate byapplications running on the mobile computing device 1250.

The mobile computing device 1250 may also communicate audibly using anaudio codec 1260, which may receive spoken information from a user andconvert it to usable digital information. The audio codec 1260 maylikewise generate audible sound for a user, such as through a speaker,e.g., in a handset of the mobile computing device 1250. Such sound mayinclude sound from voice telephone calls, may include recorded sound(e.g., voice messages, music files, etc.) and may also include soundgenerated by applications operating on the mobile computing device 1250.

The mobile computing device 1250 may be implemented in a number ofdifferent forms, as shown in the figure. For example, it may beimplemented as a cellular telephone 1280. It may also be implemented aspart of a smart-phone 1282, personal digital assistant, or other similarmobile device.

Various implementations of the systems and techniques described here canbe realized in digital electronic circuitry, integrated circuitry,specially designed ASICs (application specific integrated circuits),computer hardware, firmware, software, and/or combinations thereof.These various implementations can include implementation in one or morecomputer programs that are executable and/or interpretable on aprogrammable system including at least one programmable processor, whichmay be special or general purpose, coupled to receive data andinstructions from, and to transmit data and instructions to, a storagesystem, at least one input device, and at least one output device.

These computer programs (also known as programs, software, softwareapplications or code) include machine instructions for a programmableprocessor, and can be implemented in a high-level procedural and/orobject-oriented programming language, and/or in assembly/machinelanguage. As used herein, the terms machine-readable medium andcomputer-readable medium refer to any computer program product,apparatus and/or device (e.g., magnetic discs, optical disks, memory,Programmable Logic Devices (PLDs)) used to provide machine instructionsand/or data to a programmable processor, including a machine-readablemedium that receives machine instructions as a machine-readable signal.The term machine-readable signal refers to any signal used to providemachine instructions and/or data to a programmable processor.

To provide for interaction with a user, the systems and techniquesdescribed here can be implemented on a computer having a display device(e.g., a CRT (cathode ray tube) or LCD (liquid crystal display) monitor)for displaying information to the user and a keyboard and a pointingdevice (e.g., a mouse or a trackball) by which the user can provideinput to the computer. Other kinds of devices can be used to provide forinteraction with a user as well; for example, feedback provided to theuser can be any form of sensory feedback (e.g., visual feedback,auditory feedback, or tactile feedback); and input from the user can bereceived in any form, including acoustic, speech, or tactile input.

The systems and techniques described here can be implemented in acomputing system that includes a back end component (e.g., as a dataserver), or that includes a middleware component (e.g., an applicationserver), or that includes a front end component (e.g., a client computerhaving a graphical user interface or a Web browser through which a usercan interact with an implementation of the systems and techniquesdescribed here), or any combination of such back end, middleware, orfront end components. The components of the system can be interconnectedby any form or medium of digital data communication (e.g., acommunication network). Examples of communication networks include alocal area network (LAN), a wide area network (WAN), and the Internet.

The computing system can include clients and servers. A client andserver are generally remote from each other and typically interactthrough a communication network. The relationship of client and serverarises by virtue of computer programs running on the respectivecomputers and having a client-server relationship to each other.

In view of the structure, functions and apparatus of the systems andmethods described here, in some implementations, a system and method forperforming minimally invasive surgical techniques are provided. Havingdescribed certain implementations of methods and apparatus forsupporting minimally invasive surgical techniques, it will now becomeapparent to one of skill in the art that other implementationsincorporating the concepts of the disclosure may be used. Therefore, thedisclosure should not be limited to certain implementations, but rathershould be limited only by the spirit and scope of the following claims.

Throughout the description, where apparatus and systems are described ashaving, including, or comprising specific components, or where processesand methods are described as having, including, or comprising specificsteps, it is contemplated that, additionally, there are apparatus, andsystems of the disclosed technology that consist essentially of, orconsist of, the recited components, and that there are processes andmethods according to the disclosed technology that consist essentiallyof, or consist of, the recited processing steps.

It should be understood that the order of steps or order for performingcertain action is immaterial so long as the disclosed technology remainsoperable. Moreover, two or more steps or actions may be conductedsimultaneously.

What is claimed is:
 1. A method of performing minimally invasive spinalsurgery with a robotic surgical system, the method comprising:maneuvering a first dilator to access a vertebrae of a patient throughthe patient's muscles and skin, wherein the dilator defines a workingchannel for accessing the vertebrae; increasing the size of the workingchannel; attaching the first dilator or a subsequent dilator to the endeffector of the robotic arm using a dilator fixator; followingattachment of the first or the subsequent dilator to the end effector,repositioning the end effector thereby automatically adjusting an angleand/or position of the attached dilator with respect to the vertebraeand aligning an axis defined by the attached dilator with a desiredtrajectory during a surgical procedure without removal of the attacheddilator from the patient tissue during the repositioning.
 2. The methodof claim 1, wherein increasing the size of the working channel includes:maneuvering a second dilator over the first dilator, wherein the seconddilator is sized and shaped to slide over the first dilator and increasethe size of the working channel; and after positioning the seconddilator over the first dilator, removing the first dilator from thepatient, thereby leaving a last added dilator, wherein the attacheddilator is the last added dilator.
 3. The method of claim 2, wherein theattached dilator is the dilator with largest circumference.
 4. Themethod of claim 3, wherein increasing the size of the working channelincludes: expanding the diameter of the first dilator thereby increasingthe diameter of the working channel, wherein the dilator attached to theend effector is the first dilator.
 5. The method of claim 1, wherein themethod further comprises placing a surgical instrument guide at leastpartially inside of, in front of, or adjacent to the attached dilator,wherein the surgical instrument guide is sized and shaped to fit atleast partially inside the attached dilator along an axis defined bysaid dilator.
 6. The method of claim 1, wherein the end effectorcomprises a surgical instrument guide attached thereto, configured tohold and/or restrict movement of a surgical instrument therethrough. 7.The method of claim 6, wherein the surgical instrument guide is at leastone of a drill bit guide, tap guide, screwdriver guide, screw guide, awlguide, and implant guide.
 8. The method of claim 7, wherein the surgicalinstrument is at least one of a drill bit, tap, screwdriver, screw,implant, and awl, wherein the surgical instrument is configured to slidethrough the surgical instrument guide.
 9. The method of claim 1, whereinthe attached dilator is configured to hold and/or restrict movement of asurgical instrument therethrough.
 10. The method of claim 1, furthercomprising: registering the patient, wherein registering the patientcomprises identifying the transformation between the actual patientanatomy and one or more medical images; maneuvering the end effectortowards the vertebrae on which the surgeon will operate; determining, bya processor of a computing device, an ideal implant trajectory; andproviding, by the processor, for display on a graphical user interface,the ideal implant trajectory for review by the surgeon, wherein (i) thesurgeon may adapt the ideal implant trajectory if needed using hands-onplanning, and (ii) the surgeon acknowledges the ideal implant trajectoryor the adapted trajectory thereby causing the acknowledged trajectory tobe stored as the desired trajectory.
 11. The method of claim 1, furthercomprising, prior to maneuvering the attached dilator: moving a mobilecart transporting a robotic surgical system comprising a robotic arm inproximity to an operating table, wherein the robotic arm has an endeffector; and stabilizing the mobile cart.
 12. A robotic surgical systemfor performing minimally invasive surgery, the system comprising: arobotic arm with an end effector; a first dilator to access a vertebraeof a patient through the patient's muscles and skin, wherein the firstdilator defines a working channel for accessing the vertebrae; one ormore subsequent dilators sized and shaped to slide over the firstdilator and/or one or more of the one or more subsequent dilators,wherein: the one or more subsequent dilators comprise a last addeddilator, each of the one or more subsequent dilators are configured tobe positioned over the preceding dilators and increase the size of theworking channel, each dilator except the last added dilator isconfigured to be removed from the patient thereby leaving the last addeddilator, the last added dilator is configured to be attached to the endeffector of the robotic arm using a dilator fixator; and a manipulatorconfigured to allow robotically-assisted or unassisted positioningand/or movement of the end effector by a user with at least four degreesof freedom thereby automatically adjusting an angle and/or position ofthe last added dilator with respect to the vertebrae and aligning anaxis defined by the last added dilator with a desired trajectory duringa surgical procedure without removal of the last added dilator from thepatient tissue during the repositioning.
 13. The system of claim 12,wherein each one or more subsequent dilators have a circumference largerthan the circumference of the first dilator, and the one or moresubsequent dilators increase the size of the working channel as eachsubsequent dilator is added.
 14. The system of claim 12, comprising: asurgical instrument guide configured to be placed inside of the attacheddilator, wherein the surgical instrument guide is sized and shaped tofit at least partially inside the attached dilator along an axis definedby the dilator.
 15. The system of claim 14, wherein the end effectorcomprises the surgical instrument guide attached thereto, configured tohold and/or restrict movement of a surgical instrument therethrough. 16.The system of claim 15, wherein the surgical instrument guide is atleast one of a drill bit guide, tap guide, screwdriver guide, screwguide, awl guide, and implant guide.
 17. The system of claim 16, whereinthe surgical instrument is at least one of a drill bit, tap,screwdriver, screw, implant, and awl, wherein the surgical instrument isconfigured to slide through the surgical instrument guide.
 18. Thesystem of claim 12, wherein the attached dilator is the dilator withlargest circumference.
 19. The system of claim 12, wherein the attacheddilator is configured to hold and/or restrict movement of a surgicalinstrument therethrough.
 20. The system of claim 12, further comprising:a processor; and a memory, the memory storing instructions that, whenexecuted by the processor, cause the processor to: store atransformation between the actual patient anatomy and one or moremedical images; determine an ideal implant trajectory; and provide, fordisplay on a graphical user interface, the ideal implant trajectory forreview by the surgeon, wherein (i) the surgeon may adapt the idealimplant trajectory if needed using hands-on planning, and (ii) thesurgeon acknowledges the ideal implant trajectory or the adaptedtrajectory thereby causing the acknowledged trajectory to be stored asthe desired trajectory.